Montgomery County Department of Health and Human Services

Staff Person needs to review and ensure that it is complete

(Incomplete applications will not be considered)

1. Individual Information. Complete the section below for you and all persons who live in this household. List YOUR name first.
Last NameFirst Name / Marital
Status / Relationship To You / Date of Birth
Mo/Day/Yr / Employed / Social Security
Number (requested, not required) / Sex
M-F / Race* / U. S.
Citizen / Ethnicity
1. / SELF / / / /  Yes
 No /  Yes
 No /  Hispanic
 Non-Hispanic
2. / / / /  Yes
 No /  Yes
 No /  Hispanic
 Non-Hispanic
3. / / / /  Yes
 No /  Yes
 No /  Hispanic
 Non-Hispanic
4. / / / /  Yes
 No /  Yes
 No /  Hispanic
 Non-Hispanic
5. / / / /  Yes
 No /  Yes
 No /  Hispanic
 Non-Hispanic
6. / / / /  Yes
 No /  Yes
 No /  Hispanic
 Non-Hispanic
7. / / / /  Yes
 No /  Yes
 No /  Hispanic
 Non-Hispanic
8. / / / /  Yes
 No /  Yes
 No /  Hispanic
 Non-Hispanic
*We do not require you to provide information about your race; however, if you do, it will help show how we obey the Federal Civil Rights Law. We do not use this information for eligibility. The worker will enter a race for statistical purposes only. Required by Title VI of the Civil Rights Act of 1964.
2. Did you lose permanent housing in MontgomeryCounty? □ Yes □ No Are you homeless?  Yes  No
Last Permanent Address:
NumberStreetApt. No.Floor No. / Phone No.
CityStateZip+4 / Phone No. where you can be reached
3. List your mailing address, if different from address above
NumberStreetApt. No.Floor No.
CityStateZip+4
4. Authorized Signature
______
Signature of Applicant Date
______
Signature of Authorized Representative Date
______
Signature of Witness, if you sign with a “X” Date
If you need sign language, an interpreter or any other accommodations, please let us know.

Needs Questionnaire

Please check services that you or someone in your family needs.Date:

STAFF USE ONLY

Needs / Referred To:
Financial Services
 / Burial Assistance
 / Cash Assistance (TCA -TDAP)
 / Food Assistance
 / Food Stamps
 / Emergency Prescription Assistance
 / Housing – Eviction or Foreclosure Assistance
 / Housing – Homeless Services
 / Housing – Moving Help or Security Deposit
 / Housing – Rental Assistance
 / Medical Assistance – Coverage for Adults
 / Medical Assistance – Coverage for Children and Families
 / Personal Finances and Budgeting Assistance
 / Utilities Assistance
Health Services
 / Alcohol/Drug Treatment
 / Cancer Screening and Treatment
 / Birth Control/Contraception
 / Medical Care for Adults
 / Medical Care for Child
 / Dental Services
 / HIV/STD Testing
 / Mental Health Services – Adult
 / Mental Health Services – Child
 / Immunizations (vaccinations)
 / Pregnancy/Prenatal Services
 / Vision/Hearing Services

STAFF USE ONLY

Needs / Referred To
Family Services
 / Child Care – Help Finding Child Care
 / Child Care – Help Paying for Care
 / Child Support Payments
 / Counseling (need someone to talk with)
 / Day Care - Adult
 / Disability Support Services
 / Domestic Violence
 / Gang Prevention
 / Physical Abuse or Neglect – Adult
 / Physical Abuse or Neglect – Child
 / Services for Children ages 0-5 years – Early Childhood
 / Senior Services
 / Transportation Information
 / Victim of Crime and Sexual Assault
Other Services
 / Clothing
 / Furniture
 / Employment – non TCA
 / Immigration
 / Legal
 / Social Security
 / Other :
 / Other:
 / Other:

If you would like more information before applying for services, please call the DHHS information and Referral line, 240-777-1245.

I understand this information may be shared for referral or management purposes. DHHS staff may call me for follow-up

purposes at (phone #)______and leave a message: on voice mail Y N or with a person Y N.

Customer Name (please print) ______Customer Signature______

Montgomery County Department of Health and Human Services

Special Needs Housing

Homelessness Assessment Tool

Programs should obtain the following client documents for future applications to housing and entitlement programs:

□Proof of Income (all programs will require current income for past 30 days)

□Tax Returns

□Proof of citizenship

□Birth Certificates and Social Security Cards for all household members

□Sexual Offenders Registry Report

□MD Case Search Complete

Applicant’s Current Location: (Name of Hotel, if applicable) ______

Location Updated (if changed):

Phone(s) number they can be reached at:

Worker Completing Form: ______

Phone:

Agency Name & Address:

Documentation Checklist

Drivers License or Other Photo ID

Proof of Maryland Residency

Proof of Citizenship

Other ______

Intake Date: ______

PRESENTING PROBLEM:

Describe homeless occurrence: Explain how you became homeless:

Documentation of Homelessness:

Notarized “Put Out” letter from lease ownerEviction NoticeLetter from Provider documenting “street” homelessness

Name of Shelter/Transitional Housing / Date Enter/ Vacated / Reason for Leaving / Service Fee/ Amount Paid

Housing History

List 5 year Housing History (Include residing with whom, subsidies, and if never had lease in consumer’s name)

Adult 1 Name: ______

Residential Address / Date/length of time at that address / Total Monthly Rent or
Mortgage / Amount of monthly rent you paid / Back rent owed (amount if any) / LeaseHolder (Yes/No) / Relationship to Lease Holder / Evicted
(Yes/No) / Reason for Leaving

Adult 2 Name: ______

Residential Address / Date/length of time at that address / Total Monthly Rent or
Mortgage / Amount of monthly rent you paid / Back rent owed (amount if any) / Lease Holder (Yes/No) / Relationship to Lease Holder / Evicted
(Yes/No) / Reason for Leaving

Employment History – Adult 1 Name: ______

Employer Name / Dates of Employment / Gross Wages/
Salary / Full/PT/Seasonal/
Temporary / City/State / Reason for Leaving
 Full Time
 Part Time ___
 Seasonal
 Temporary
 Self Employed
 Full Time
 Part Time ___
 Seasonal
 Temporary
 Self Employed
 Full Time
 Part Time ___
 Seasonal
 Temporary
 Self Employed
 Full Time
 Part Time ___
 Seasonal
 Temporary
 Self Employed

Adult 1 - Education

Highest Grade Level CompletedHS Diploma (Yes / No) ______

Obtained GED (Yes / No) ______

Certifications or Other Training

Adult 2 Name: ______

Adult 2 - Education

Highest Grade Level CompletedHS Diploma (Yes / No) ______

Obtained GED (Yes / No) ______

Certifications or Other Training

Budget/Expenses Resources

Budget should evolve as clientsituation changesBudget Revised (date) ______

Monthly Expenses / Monthly Cost / Income/Benefits
(Gross Amounts) / Monthly Amount
Auto Insurance / Employment
Car payment / Military Disability Income
Child Care / Social Security Disability Income
Child Support / Supplemental Security Income
Credit Cards (total) / Social Security Retirement Income
Groceries / Retirement/Pension/Annuity
Medical Bills / Temporary Cash Assistance (TCA)
Storage / Temporary Disability Assistance Program (TDAP)
Student Loans / Unemployment
Telephone / Veterans Pension
Transportation (metro) / Other
Wage Garnishments / Other
Utilities
Other / Monthly Net Income $ / XXXXXXXXXXXXX
Total Monthly Expenses / Gross Total

Estimated amount available to housing cost(Net Income minus Monthly Expenses):

Other Assistance: Medical Assistance: Yes No WPA/POC: Yes No Amount:

Supplemental Nutritional Assistance Program (Food Stamps) Amount: Income Tax Credit – (Yes / No)Amount: ______Received Tax Return? If yes, $______

Veterans Administration Medical Services Yes No Start Date:

Medicare: ______Primary Adult Care (PAC): ______

Grant History: Please list amounts of grant family/individual have received in the past 12 months.

Welfare Avoidance Grant: CountyEmergencyServices (ES)

Emergency Assistance to Family’s with Children (EAFC): Other:

Credit/Debt History

Credit History (HOC, landlords, loans, credit cards, medical bills etc.)

Creditor / OutstandingBalance / Months Past Due / Amount Paid to Date

Check box if ever declared bankruptcy

Describe any Repayment Plan Development:

List outstanding utility company balances

Service / Amount Owed / Months past due

Additional Comments / Supporting Information:

Assets Information

Requested Credit Report: Yes ___ No ___

If yes, date requested: ______

Account / Yes/No / Name of Bank / Balance (even if $0.00)
Checking
Saving
Other

Have you ever served in the Military/National Guard (Yes / No)

Are you a Veteran (Yes / No)Please complete if any member in household served in the military

Military Service (anymember of the family)

Person / Branch / Dates of Service / War Zone Service/Date / Discharge Type
Absent Parent
Name / Last known address / Name of Child / Phone # / Date of Last Contact / Housing Option (Yes/No)

Family/FriendContacts:

Name / Relationship / City/State / Phone # / Date of Last Contact / Housing Option

Legal History

Worker has checked the sex offender’s registry list and MD Criminal Data base for any violent crimes i.e. burglary/assault?Yes / No

Detailed explanation:

Ever incarcerated? Yes / No If yes, when/where:

Currently on probation or parole?

Yes No If yes, name of parole/probation officer and phone number:

Other

Medical Conditions or Disabilities? Yes / No

Medications taken for medical or psychiatric illness? Yes / No if yes, complete box below

History of physical/sexual abuse as an adult or child (Yes / No)

History of adult / child mental health (Yes / No)

Substance Abuse History Yes / No Will urinalysis results be positive? Yes / No if yes, for what substance(s)?

Past or current Child Welfare involvement? Yes / No

Workers Observations / Comments

Housing referral made: Yes or No, to where Date Sent: ______

School Verification obtained: Yes or No Day Care Subsidy: Yes or NoDay Care Placement: Yes or No

Transportation arranged for school: Yes or No

□Completed assessment tool uploaded to Service Point as an Attachment

(Assessment Tool 4-5-11 Revised)

Housing Options

Targeting Tool

Housing History (choose only one) / Point Value
One eviction or negative landlord report / □ / 1
More than one eviction or negative landlord reports / □ / 2
No rental history – never had lease in own name / □ / 2
Credit/Debt History (check all that apply) / Point Value
Outstanding utility balance(s) / □ / 1
Lack of credit history / □ / 1
Poor credit history / □ / 2
Owes former landlord / □ / 2
Wages currently garnished / □ / 2
Bankruptcy / □ / 3
Income/Employment (choose only one) / Point Value
Employed – income falls between 30% - 50% area median income / □ / 1
Employed – income falls below 30% median income / □ / 2
No income/TCA/TDAP – recent/temporary loss of employment; however, good work history / □ / 1
No income/TCA/TDAP – fair to no employment history / □ / 2
Fixed income – unlikely to change (SSI, SSDI, Retirement) / □ / 3
Criminal History (check all that apply) / Point Value
One or two misdemeanors / □ / 2
More than three misdemeanors / □ / 3
Felony conviction / □ / 3
Sexual assault crimes / □ / 3
Arson conviction / □ / 3
Substance Abuse/Mental Health (check all that apply) / Point Value
Currently in mental health treatment / □ / 3
Currently in substance abuse treatment / □ / 3
History of substance abuse or mental health issue – not currently in treatment / □ / 3
Other Barriers (check all that apply) / Point Value
Domestic violence issues / □ / 1
Family size of 7 or more / □ / 2
Eviction history from HUD or transitional housing program / □ / 3
Undocumented / □ / 2
Moderatemonthlyassistance needed to maintain housing / □ / 5
Limited Independent Living Skills / □ / 7
Documented Permanent Disability / □ / 15
Total all points and check housing level below. Total Score
Housing Referral Recommendation
Level 1 -- No Significant Barriers to Obtaining Housing
(Barrier Score < 7)
□No Housing Subsidy needed / Level 2 -- Minimal Barriers to Obtaining Housing
(Barrier Score 7-15)
□Subsidized housing, short or long term shallow or deep subsidy with some or no supports (HPRP, State RAP, etc.) / Level 3 -- Moderate to Major Barriers to Obtaining & Maintaining Housing
(Barrier Score 15 + )
□Permanent Supportive and Transitional Housing (McKinney, HIP, transitional, housing for families, PPH, etc.) Deep subsidies and case management.
Notes: